The New Hampshire (NH) Title V Program is a partnership of the United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) with New Hampshire’s Department of Health and Human Services’ Maternal and Child Health (MCH) and Children and Youth with Special Health Care Needs (CYSHCN) programs. In NH, the CYSHCN program is called Special Medical Services (SMS). Together, these Title V programs support core public health functions including direct, enabling, population-based, and infrastructure-building services in the following areas: maternal and child health; children with special health care needs; adolescent health; teen pregnancy prevention; family planning; primary care; perinatal health; home visiting; early childhood systems building; injury prevention and surveillance; newborn screening and early intervention; and surveillance and information delivery about the MCH and CYSHCN population.

 

New Hampshire’s Title V programming focus comes from the MCH and CYSHCN population’s priority needs. A five-year needs assessment was conducted in 2015 and is updated yearly. In conjunction with a comprehensive data review, specific input from the public and other stakeholders as well as a capacity assessment, a list of priority issues emerged and became the basis of programming through 2020. Additional information, data and stakeholder/public input are gathered routinely within the scope of work of each Title V program. This collaborative and evidence-based approach is most likely to leverage the greatest improvement on the health of the NH population.

 

Some of the participating groups in the needs assessment process included Spark NH, which is the Governor’s Early Childhood Advisory Council; Family Resource Centers; Bureau of Family Assistance; NH Autism Council; Safe Kids NH; Injury Prevention Advisory Council; Brain Injury Association; Nashua Division of Public Health and Community Services; community health centers; Bureau of Drug and Alcohol Services; Drug Free NH; NH Pediatric Improvement Partnership; and NH Family Voices.

 

Title V staff by consensus established the following list of priorities to steer programming through the five-year period 2015-2020:

 

 

In 2017-2018, during the course of routine activities of MCH staff with MCH-contracted agencies (Primary Care, Title X Family Planning, Home Visiting), opinions were solicited and the following observations and concerns were noted, all of which are highly concordant with the current list of eight priority needs:

 

• Increased opioid use, mainly among young to middle aged adults, impacts the needs and well-being of children and other family members
• Insufficient mental health services, notably for children and adolescents
• The costs of health care – even with the ACA many individuals have high out-of-pocket expenses, putting even basic care out of reach
• Health care worker shortage
• Community Health Centers report insufficient reimbursement mechanisms, with the result that not all individuals have equal access to “routine” testing or services

 

Likewise a public input survey conducted in 2018 showed that the eight selected priority needs were considered Highly Important or Important by a large majority of respondents, demonstrating that these eight priorities remain highly pertinent through this project cycle.

 

An in-house report on Health Equity among pregnant women (utilizing PRAMS 2013-2017 data)

examined disparities among subgroups. It was found that the greatest number of inequities were due to income, education, and age. But a significant number of disparities were also found to be due to nativity (US-born vs. foreign-born), race/ethnicity, and residence (urban vs. rural, as well as county or city of residence).

 

In order to address the State’s priority needs and in keeping with the Title V framework, Title V staff selected the following National Performance Measures (NPMs) and State Performance Measures (SPMs) which are driving program planning and strategies in the various population domains:

 

NPM#1: Percent of women with a past year preventive medical visit

To address priority need#1: Improve access to needed healthcare services for all populations;

Domain: Women/Maternal Health

 

NPM#5: Percent of infants places to sleep on their backs

To address priority need #7: Decrease unintentional injury;

Domain: Perinatal/Infant Health

 

NPM#6: Percent of children, ages 9 through 35 months, receiving a developmental screening using a parent-completed screening tool in the past year.

To address priority need #8: Improve access to standardized developmental/social emotional screening, assessment and follow-up for children and adolescents;

Domain: Child Health

 

NPM#7.2: Rate of hospitalization for non-fatal injury per 100,000 adolescents ages 10 through 19.

To address priority need #7: Decrease unintentional injury;

Domain: Adolescent Health

 

NPM#8.1: Percent of children ages 6-11 who are physically active at least 60 minutes per day.

To address priority need #5: Decrease pediatric overweight and obesity;

Domain: Child Health

 

NPM#10: Percent of adolescents, ages 12-17 with a preventive medical visit in the past year.

To address priority need #1: Improve access to needed healthcare services for all populations;

Domain: Adolescent Health

 

NPM#11: Percent of children with and without special health care needs who have a medical home

To address priority need #3: Increase access to comprehensive medical homes;

Domain: Children with Special Health Care Needs

 

NPM#14.1: Percent of women who smoke during pregnancy

To address priority need #2: Decrease the use and abuse of alcohol, tobacco and other substances among youth, pregnant women, and families;

Domain: Women/Maternal Health

 

SPM#1: Percentage of MCH-contracted Community Health Centers with an Enabling Services workplan on file with MCH

This state-specific measure was created to address priority need #1: Improve access to needed health care services for all populations;

Domain: Cross-cutting/Systems-building

 

SPM#2: Percentage of families enrolled in Special Medical Services who report access to respite services

This state-specific measure was created to address priority need #6: Increase family support and access to trained respite and childcare providers;

Domain: Children with Special Health Care Needs

 

SPM#3: Percentage of behavioral health professionals recruited

This state-specific measure was created to address priority need #4: Improve access to mental health services;

Domain: Cross-cutting/Systems-building

 

Strategies aiming to improve these performance measures are delineated in each population domain, in the State Action Plan table of this report.

 

Access to services is highlighted in five of the eight state priorities. Consequently, New Hampshire’s Title V program has taken on the task of enhancing access to quality health care services for the MCH and CYSHCN population. Many Title V contracted agencies utilize the funding they receive to keep family and community health services available when no other resources can be utilized. Title V funding decisions are based on gap assessments founded on discussions of the state’s health care system and the needs assessment process which looks at health outcomes. Grant funds go towards agency staffing infrastructure as well as contractual services.

 

Title V leads by calling attention to emerging issues in the field, thinking strategically and facilitating analysis about what is currently happening on a local level and nationally, and educating on best practices. Title V is a convener as well as a participant in many different statewide workgroups. Title V staff members created, organized and currently facilitate several programmatic advisory committees, mortality review groups as well as collegial workgroups.

 

With Title V funding, New Hampshire’s MCH program supports 14 Community Health Centers (CHCs) in their mission to provide accessible and affordable comprehensive primary care services, including prenatal and pediatric care, for some 127,548 individuals and 1,774 pregnant women in 2018. Most of the funding is currently being used for quality improvement, for projects such as getting adolescents into annual health care; increasing the number of pregnant women and the homeless referred for and actually receiving tobacco cessation activities; and increasing the number of highly effective contraceptive methods used among reproductive age women. MCH uses Title V funds to support enabling services such as case management, transportation and interpretation services.

The SMS Bureau, through their Title V funds, supports 11 programs including a network of child development clinics for pediatric diagnostic evaluation services; an interdisciplinary clinic for neuro-motor disabilities and a Complex Care Network that incorporates statewide interdisciplinary clinics and specialty consultation to providers serving children and youth with special health care needs; a nutrition, feeding and swallowing program with community-based consultation and intervention services utilizing a home visiting framework; a medical home project and psychiatry consultations for CYSHCN. SMS continues to support NH Family Voices (NHFV) in its mission to assist families with CYSHCN by providing information, support, and referral.

 

The stewards of Title V do not work in a vacuum. All efforts are undertaken in conjunction with many partners, both state and federal, who focus on maternal and child health, including children and youth with special health care needs. Title V monies are usually leveraged with other funding to ensure access to quality health care and needed services for the MCH population. For example, many of the MCH-contracted CHCs utilize their Title V funding for staffing that is not otherwise covered by other grants or fees for services through insurance.

 

An Intra-Agency Agreement (IAA) between NH Title V custodians (Maternal and Child Health and Special Medical Services) and the Division of Medicaid Services sets out the framework and conditions for joint planning, coordination and improvement of programs under Title V MCH and Title XIX Medicaid. The IAA outlines and codifies:

 

• Collaboration on the development and implementation of quality health standards.
• Improvement in referral processes and access to and utilization of health services.
• Implementation of processes for making intra-agency decisions and coordination of policies.
• Reduction of duplicative services and implementation of innovative solutions to health care issues.
• Assurance of compliance with federal and state statutes.
• Promotion of joint planning, monitoring and evaluation of a health care system for the Title V MCH and Title XIX Medicaid populations.

 

A new element in this agreement is the assignment of a seat for MCH on the Medicaid Medical Care Advisory Committee (MCAC) which advises the Medicaid Director on policy and planning. Members of the MCAC must be familiar with the comprehensive needs of low-income population groups and with the resources required for their care, which is consistent with the professional responsibilities of Title V staff.

 

The IAA reaffirms the commitment to have Title V funded agencies identify, enroll and re-enroll Medicaid-eligible clients and to refer those clients to appropriate services. Many CHCs utilize Title V funds for sustaining or increasing staff capacity to assist with client insurance needs, since up to one-third of clients coming into their agencies for the first time are uninsured, and other federal funding for patient navigators has greatly diminished. As part of its Title V funded contract with SMS, NH Family Voices (whose staff are trained as navigators) also offers assistance with understanding options and accessing Medicaid.

 

MCH and the Medicaid Office of Quality Assurance and Improvement (QAI) are collaborating on an evaluation of Medicaid policy change regarding coverage of labor and delivery services and contraception services, to determine the impact on pregnancy intention and pregnancy timing. Medicaid and SMS together created an option for families whose child is experiencing a developmental delay to be able to receive rehabilitative services through Medicaid and still be eligible to receive services through Part C Early Intervention.

 

SMS has a very strong and longstanding collaboration with NH Family Voices (NHFV). SMS has funded parent consultation and support through NHFV for more than 20 years. This partnership includes the provision of office space, allowing NHFV and SMS to be co-located. In addition to the initial activities of helping families to access services, this partnership has evolved to include leadership and policy development, including administrative rules changes and Medicaid Managed Care communication and training.

 

MCH and the Division for Children, Youth and Families (DCYF) together leverage funding for 12 Comprehensive Family Support Services home visiting contracts that function by intervening at critical periods of stress and transition for pregnant women, children, and families with children up to the age of 21.

 

SMS braids funding with DHHS’s Bureau of Developmental Services for a contract that enhances access for children and youth with special health care needs to psychiatric assessment, consultation, and short-term condition/medication management.

 

In this final year of the current project cycle, NH Title V is requesting technical assistance (TA) for:

 

(1) the facilitation of a Capacity Assessment for State Title V (CAST V) process as part of its 2020 needs assessment;

(2) a facilitated discussion on follow-up coordination between the MCH unit and the SMS unit, which are located on separate campuses but whose staff need to interact routinely on the follow-up of birth conditions and newborn hearing screening, for referral to services;

(3) the provision of evaluation expertise to MCH’s Injury Prevention Program (IPP) by the Center for Program Design and Evaluation (CPDE) at Dartmouth for the development of an evaluation plan specific to NPM#7, the rate of hospitalization for non-fatal injury for adolescents ages 10 through 19;

(4) a workshop and follow-up consultation from the Center for IDEA Early Childhood Data Systems for Title V staff and partners, on data governance and management;

(5) the development of formal guidance for Targeted Case Management (TCM) billing, to better integrate and eliminate duplication of services; and

(6) the development of a standardized formula for establishing caseload limits for CYSHCN served under the Health Care Coordination program.

 

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